Constructing the questionnaire

The results of the II Delphi- round’ s statements assessing the perceptions of the three sub-panels, and especially the generous argumentation obtained of the importance of issues to be taken into account also in the latter parts of the study, influenced directly the preparation of the III Delphi- round. After each statement the researcher compiled a simple list of arguments in favour of and against the realisation of the statement concerned. Very long lists of single words and short expressions were thus assembled. These, in turn, might have been useful to be attached to the questionnaire of the III Delphi- round for the panellists to have possibility to scrutinize all the original expressions. This was not, however, done mainly due to fear of overstraining the panellists with excessive amounts of material. Completing the questionnaire itself turned out to be quite a burden. After all, the argumentation had remarkable impact on the III Delphi- round’ s form.

The questionnaire was constructed to contain four parts (A – D), as follows. A) An introduction, where the purpose and aims of the study were explained. B) The actual questionnaire, first containing three alternative future scenarios dealing with the possible changes in the working environments and operational policies of ED work in the long range future, approximately in the year 2020. The descriptions of the aforementioned issues concerning the possible futures were prepared on the basis of the results obtained during the second phase of the study, and the background information was provided for the participants along with the questionnaire. As explained previously the results of the II Delphi- round, especially in terms of the operational environment of future ED nurses, were taken into account when constructing the scenarios.

In the short instruction to part B, the respondents were asked to comment on the scenarios in the form of answering the questions: What is the most probable scenario, and on what grounds? What is the most desirable scenario, and on what grounds? Does the panellist wish to eliminate something from, or add something to the scenario chosen. If yes, what would it

be. The scenarios were entitled as follows: A) ‘Business as usual’; B) ‘ED nurses’ profession is evolving’; and C) ‘The system is in danger of collapsing’.

The scenarios were constructed around nine variables, which were included in each of the three scenarios. The manifestation and essence of the nine variables were, in turn, changed according to the assumed state of affairs in each scenario. The variables were as follows: 1) The degree of centralisation of emergency health care services; 2) The overcrowding situations in the EDs; 3) The training and education of nurses working in the EDs; 4) The independence of the nursing profession within the EDs; 5) Availability of nursing personnel;

6) Operational policies and models of action in the EDs; 7) The role of MDs in the EDs; 8) ED patient material; and 9) The state of patient satisfaction. A summary of the nine variables and the way they were presented in each scenario is provided in Appendix 9. The variables were derived, in addition to what was mentioned on previous page, from the issues affecting on background of the study and presented first in chapter 3.

Scenario I ‘Business as usual’ was constructed to describe a future much like the prevailing situation, as the name of the scenario also indicates. No special educational program for ED nursing has been implemented, but triage nurse’ s role has been officially acknowledged.

Dissatisfaction among patients has increased, and overcrowding situations come about.

Nevertheless, the situation is mainly under control

According toScenario II ‘ED nurse’ s occupational profile is evolving’ the future appears in a positive light. The heavy centralisation of emergency health care services has turned out to be beneficial. The structural and operational reforms implemented have yielded a more fluent and less congested reality to prevail in the EDs, which have become magnet units with remarkable reduction of the turnover of the nursing personnel. The educational level as well as the independence of ED nurses’ profession has increased. These reforms have, together with other reforms, resulted in the ability of EDs to respond to patients’ needs in a satisfactory way. Complaints are received more seldom even though patient material has become more demanding. This scenario intentionally overestimates the overflowing importance of ED nurses’ role in terms of the positive state of affairs described.

An extremely heavy centralisation on emergency health care services are described in theIII scenario named ‘The system is in danger of collapsing’. The EDs left are struggling with continuously worsening problems, and a survival game might better describe the reality of

this ‘horror’ scenario. This scenario intentionally presents a future, where everything that can go wrong, also has done so. Both the amount and educational level of nursing personnel in the EDs are grossly insufficient, and the medical profession is suffering from he same problems.

Patient satisfaction has collapsed severely, and malpractice complaints are received continuously.

The descriptions of the scenarios were intentionally very pointed in order to stimulate argumentation, but this was, by a few panellists, regarded as over-emphasising the role of an ED nurse in the future health care. Admittedly, this was to some extent the case, and a more comprehensive introduction to the purpose of this part of the study and the meaning of the scenarios might have been useful. On the other hand, the questionnaire itself was already lengthy and unarguably a significant burden of work, especially as some of the panellists had already taken part in both previous phases of the study.

Part B of the questionnaire also included statements or ‘mini-scenarios’ concerning future operational policies of ED nurses’ work. The construction of the “mini-scenarios” was based mainly on the results of the II Delphi- round, as well. However, these results are not reported separately in this research report, as they were intended to impact indirectly on the final results of the study, which also realized. All those statements the mean importance of which was estimated by the respondents to be over 50 of 100 during the II Delphi- round were counted in this phase of the study. These statements were based on the responses to the second phase of the study and a report of The Ministry of Social Affairs and Health (Hukkanen and Vallimies-Patomäki 2005) dealing with co-operation and division of work in securing access to care. The respondents were asked to choose either alternative in terms of both the probability and desirability of each statement of the ‘mini-scenarios’. Comments for justification of the respondents’ choices were asked along with each statement.

In part C of the questionnaire, the respondents were provided with background information concerning knowledge of the future of health care in order to facilitate the orientation to futures thinking of the respondents. The background information was gathered from one scientific article dealing with the future of European health care (Saritas and Keenan 2004), and from a report of the Committee for the Future of the Finnish Parliament ‘The Future of Finnish Health Care. Strategies and scenarios to secure health care services in Finland in the future’ (The Parliament of Finland 8/2004). These sources were selected on the grounds of

their scientific accuracy and relevance, and for their time frame being close to the one chosen for this study.

Part D provided an alphabetical list of the Delphi panellists (N = 36) accompanied with the panellists’ background organisation. This was done in order to enhance the motivation of the respondents’, by providing the opportunity to understand the composition of the whole panel.

However, it was clearly stated that the outcomes from the panellists would be reported strictly anonymously. Finally, all the mailed questionnaires were again accompanied with a return envelope with author’s address and stamp on it.

The panellists were not provided any recommendations or instructions of how to organize their work. Most probably they have all worked as individuals without contacts to other panellists. As mentioned already they were provided an alphabetical list of names of the whole panel, but no information of how the panel has been constructed or what sub-panel the panellist is representing. This was due to a wish to get the panellists to share their valuable information as unbiased as possible, and primarily from the standpoint of the individuals in question. This wish was considered appropriate regardless of the scientific underpinning that each individual was recruited to represent one of the sub-panels. The information policy issues emphasized by Kuusi (1999) had to be taken into account, again.

5.3.2 Analyses of the data

The panellists’ comments on the scenarios were simply counted and tabulated as figures and percentages in terms of the probability and desirability of the scenarios A – C. Arguments in favour of and against each scenario are presented as a summary accompanied, with direct citations as well as issues desired to be removed from or added to the scenario in focus. The summaries were compiled by conducting a content analysis of the arguments.

The ‘mini-scenarios’ are presented as tables consisting of frequencies in terms of the assessments of the probability and desirability of the ‘mini-scenarios’ (Tables 7–19). The argumentation in favour of and against the probability and desirability is provided after each

‘mini-scenario’ as a summary, also accompanied with direct citations. The summaries are compiled in the aforementioned way.